SOLE’S INTRODUCTION TO
CRITICAL CARE NURSING
9TH EDITION
• AUTHOR(S)MARY MAKIC
TEST BANK
1
Reference
Ch. 1 — Clinical Judgment Measurement Model & Standards
Stem
A charge nurse on a 6-bed ICU notices that a newly admitted
post-op patient has a rising heart rate from 88 to 118 bpm over
30 minutes, RR 24, SpO₂ 92% on 2 L NC, and a temperature of
38.3°C. The bedside nurse is new and appears uncertain. As the
charge nurse, what is the best immediate action?
A. Ask the bedside nurse to repeat the assessment and call the
surgeon if findings persist.
,B. Perform a focused bedside assessment yourself and initiate
the unit's early deterioration protocol.
C. Document the vitals and continue routine hourly monitoring
since changes are mild.
D. Notify the charge anesthetist and request orders for
antipyretics before any further action.
Correct Answer
B
Rationales
Correct (B): The charge nurse must apply the Clinical Judgment
Measurement Model—recognize changes, prioritize, and
intervene. A focused assessment identifies early deterioration
(tachycardia, fever, mild hypoxia) and starting the unit early
deterioration protocol (e.g., sepsis screening, increased
monitoring, notifying the team) is the safest priority.
A: Asking the new nurse to repeat delays decisive assessment;
leadership role requires direct action when patient risk is rising.
C: Passive documentation ignores progressive physiologic
changes and risks deterioration—hourly monitoring is
insufficient.
D: Notifying anesthetist and giving antipyretics without
assessment and protocol initiation misses broader causes of
tachycardia/fever.
Teaching Point
Leaders should assess and activate early-deterioration
protocols—don’t delegate initial triage when risk rises.
,Citation
Makic, M. B. F. (2025). Sole’s Introduction to Critical Care
Nursing (9th ed.). Ch. 1.
2
Reference
Ch. 1 — Quality and Safety Emphasis
Stem
During bedside shift report, the ICU nurse realizes the central
line dressing for a patient with an indwelling catheter was not
changed per policy and tubing label shows last change 72 hours
ago. The patient is stable but septic risk is a concern. What
should the nurse do first?
A. Plan to change the dressing at the end of the shift when
staffing is lighter.
B. Immediately change the dressing using aseptic technique and
document action.
C. Notify the physician and request a blood culture before
touching the line.
D. Remove the central line and place a peripheral IV for
antibiotics.
Correct Answer
B
Rationales
Correct (B): Quality and infection-prevention standards require
, immediate corrective action—perform aseptic dressing change
now to reduce CLABSI risk and document. This aligns with
safety emphasis and evidence-based practice (timely catheter-
site care).
A: Delaying increases infection risk and violates unit standards.
C: Notifying for cultures may be appropriate if infection
suspected, but immediate aseptic correction of a breached
dressing is higher priority to reduce ongoing contamination.
D: Removing a line without provider order and without
assessing risk/benefit is outside nursing independent scope
unless emergent.
Teaching Point
Fix breaches in infection prevention immediately—timely
aseptic care reduces CLABSI risk.
Citation
Makic, M. B. F. (2025). Sole’s Introduction to Critical Care
Nursing (9th ed.). Ch. 1.
3
Reference
Ch. 1 — Certification & Professional Organizations
Stem
A recently hired ICU nurse asks you whether pursuing CCRN
certification will impact their practice. Which response best
reflects the professional/quality rationale?
CRITICAL CARE NURSING
9TH EDITION
• AUTHOR(S)MARY MAKIC
TEST BANK
1
Reference
Ch. 1 — Clinical Judgment Measurement Model & Standards
Stem
A charge nurse on a 6-bed ICU notices that a newly admitted
post-op patient has a rising heart rate from 88 to 118 bpm over
30 minutes, RR 24, SpO₂ 92% on 2 L NC, and a temperature of
38.3°C. The bedside nurse is new and appears uncertain. As the
charge nurse, what is the best immediate action?
A. Ask the bedside nurse to repeat the assessment and call the
surgeon if findings persist.
,B. Perform a focused bedside assessment yourself and initiate
the unit's early deterioration protocol.
C. Document the vitals and continue routine hourly monitoring
since changes are mild.
D. Notify the charge anesthetist and request orders for
antipyretics before any further action.
Correct Answer
B
Rationales
Correct (B): The charge nurse must apply the Clinical Judgment
Measurement Model—recognize changes, prioritize, and
intervene. A focused assessment identifies early deterioration
(tachycardia, fever, mild hypoxia) and starting the unit early
deterioration protocol (e.g., sepsis screening, increased
monitoring, notifying the team) is the safest priority.
A: Asking the new nurse to repeat delays decisive assessment;
leadership role requires direct action when patient risk is rising.
C: Passive documentation ignores progressive physiologic
changes and risks deterioration—hourly monitoring is
insufficient.
D: Notifying anesthetist and giving antipyretics without
assessment and protocol initiation misses broader causes of
tachycardia/fever.
Teaching Point
Leaders should assess and activate early-deterioration
protocols—don’t delegate initial triage when risk rises.
,Citation
Makic, M. B. F. (2025). Sole’s Introduction to Critical Care
Nursing (9th ed.). Ch. 1.
2
Reference
Ch. 1 — Quality and Safety Emphasis
Stem
During bedside shift report, the ICU nurse realizes the central
line dressing for a patient with an indwelling catheter was not
changed per policy and tubing label shows last change 72 hours
ago. The patient is stable but septic risk is a concern. What
should the nurse do first?
A. Plan to change the dressing at the end of the shift when
staffing is lighter.
B. Immediately change the dressing using aseptic technique and
document action.
C. Notify the physician and request a blood culture before
touching the line.
D. Remove the central line and place a peripheral IV for
antibiotics.
Correct Answer
B
Rationales
Correct (B): Quality and infection-prevention standards require
, immediate corrective action—perform aseptic dressing change
now to reduce CLABSI risk and document. This aligns with
safety emphasis and evidence-based practice (timely catheter-
site care).
A: Delaying increases infection risk and violates unit standards.
C: Notifying for cultures may be appropriate if infection
suspected, but immediate aseptic correction of a breached
dressing is higher priority to reduce ongoing contamination.
D: Removing a line without provider order and without
assessing risk/benefit is outside nursing independent scope
unless emergent.
Teaching Point
Fix breaches in infection prevention immediately—timely
aseptic care reduces CLABSI risk.
Citation
Makic, M. B. F. (2025). Sole’s Introduction to Critical Care
Nursing (9th ed.). Ch. 1.
3
Reference
Ch. 1 — Certification & Professional Organizations
Stem
A recently hired ICU nurse asks you whether pursuing CCRN
certification will impact their practice. Which response best
reflects the professional/quality rationale?
